PHYSICAL EXAMINATION

VS: T 38.4°C, P 104, R 16, BP 112/68

PE: Pelvic examination revealed a reddened cervical os (Fig. 30-1). Lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness were noted. The uterus, fallopian tubes, and ovaries were also tender but were not enlarged.

FIGURE 30-1 View through vaginal speculum showing reddened cervical os, through which mucopurulent secretion is exuding.

(Courtesy of Dr. Jeanne Sheffield, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.)

LABORATORY STUDIES

Blood

ESR: 31 mm/h

Hematocrit: Normal

WBC: 13,400/μL

Differential: 68% PMNs, 8% bands, 15% lymphs

Imaging

Not done

Diagnostic Work-Up

A clinical diagnosis of PID was considered based on positive pelvic examination (adnexal tenderness and cervical motion tenderness). An endometrial biopsy or aspiration may reveal evidence of inflammation supporting the clinical diagnosis. Table 30-1 lists the likely causes of this PID. Investigational approach may include

• Microscopy

• Gram stain of vaginal discharge for Neisseria gonorrhoeae

• Giemsa or direct fluorescent antibody stain of cytobrush specimen of endocervix for Chlamydia trachomatis (urine antigen in male patients)

• Cultures for N. gonorrhoeae and Chlamydia and anaerobic cultures of endometrial aspiration to confirm polymicrobic infection

TABLE 30-1 Differential Diagnosis and Rationale for Inclusion (consideration)

Rationale: A clinical diagnosis of pelvic inflammatory disease (PID) should be considered. There are many pathogens associated with PID, but the pathology is generally the same. Gardnerella and Group B streptococcus are common organisms in the female genital tract. N. gonorrhoeae and C. trachomatis should be considered in sexually active patients. Often, multiple organisms are present, particularly anaerobes along with facultative anaerobes. A. israelii is often associated with intrauterine contraceptive devices.

If all of the aforementioned fail, N. gonorrhoeae or C. trachomatis can be detected in endometrial biopsy by (1) 16S rRNA probes, (2) polymerase chain reaction, or (3) ligase chain reaction.